International Journal of the Addictions
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Psychiatric Aspects of Drug Addiction in Lebanon Herant A. Katchadourian & Jeffrey V. Sutherland To cite this article: Herant A. Katchadourian & Jeffrey V. Sutherland (1975) Psychiatric Aspects of Drug Addiction in Lebanon, International Journal of the Addictions, 10:6, 949-962, DOI: 10.3109/10826087509028353 To link to this article: http://dx.doi.org/10.3109/10826087509028353
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The International Journal of the Addictions, lo(@, pp. 949-962, 1975
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Psychiatric Aspects of Drug Addiction in Lebanon Herant A. Katchadourian, M.D. Stanford Medical Center Stanford, California
Jeffrey V. Sutherland, M.S.* Department of Mathematics United States Air Force Academy, Colorado
The problem of narcotics abuse in Lebanon is significant on several counts. There is a tradition of hashish usage in the area that goes back many centuries. In more recent times, Lebanon has been identified as an important way-station in the international heroin traffic that moves Turkish opium to Lebanon where it is converted to morphine base, and on to Marseille where it is further processed to heroin destined for New York (Weissman, 1965). Also, Lebanon itself produces a considerable amount of hashish for local consumption as well as presumably for export. According to one account, the more extensive growing of hashish in Lebanon dates back to 1922 when it was introduced by an Ottoman officer
* To whom correspondence should be addressed at the Department of Biometrics, University of Colorado Medical Center, 4200 East Ninth Avenue, Denver, Colorado 80220. 949 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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to the Beqa’a valley where it is now primarily grown. Given the suitable climatic and soil conditions, its cultivation has since then rapidly spread so that by the midsixties the yearly output was estimated at about 150 tons. Governmental agencies have been quite aware of this situation but have not instituted rigorous control measures since the economy of some 50 to 60 villages in the area is based on this product. Since wholesale destruction of the hashish fields would leave substantial numbers of peasants destitute, one experimental plan has been to help hashish growers to shift to the cultivation of sunflowers, which would do equally well in the arid climate and whose seeds could provide a marketable substitute cash crop. Arab states have traditionally paid little attention to the problem of drug addiction within their countries. This has been partly due to ignorance of the extent of the problem reinforced by the fiction that while people admittedly export these products, they are “too smart” to use it themselves. It has also been alleged that powerful political figures with investments in such trade have successfully blocked effective control measures. During the past decade or so, these attitudes have changed somewhat and there is now a t least a recognition of the seriousness of the problem. Drug addiction is predominantly a lower income class phenomenon in Lebanon almost exclusively involving males. Until and unless drug use interferes with a man’s earning his livelihood, it is unlikely to attract adverse notice within the user’s immediate community. The middle class population is vaguely aware of the issue, mostly through periodic magazine articles that highlight the more dramatic aspects of drug traffic. In one suburb of Beirut a physician who was a known and severe morphine addict was openly tolerated and continued to practice for years although people did not have much confidence in his judgment. There are no extensive or accurate statistics about the prevalence of drug addiction in Lebanon or the rest of the Arab East. In a comprehensive survey of the psychiatric literature on this area, Racy lists a number of studies from Egypt and the Sudan by El-Maghrabi, Soueif, and El-Mahi as well as a number of review papers for the World Health Organization by the last author (Racy, 1970). There is also one reference to addiction in Lebanon abstracted from the 1962 Annual Report of the Ministry of Public Health based on data provided by J. Haikal, the psychiatric consultant to the Ministry for problems of drug addiction. Haikal’s figures include all drug addicts who were in jail and in the forensic unit of the Lebanon Hospital for Mental and Nervous Disorders at Asfurieh. As summarized by Racy, Haikal’s statistics are as follows: 90% of addicts are male; heroin is the most frequently used agent (hashish and
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cocaine come next); 87.5% of all addicts are 20-39 years old; 85% of all addicts come from the lowest socioeconomic class and most are laborers; 97% of the addicts are close to illiteracy (very little or no schooling); 50% start addiction “under the influence of friends and environment”; and about 90% come from Beirut and its suburbs. The total number treated at the hospital in 1962 was 257; 51% were readmissions (Racy, 1970). The data reported here emanate from a comprehensive survey of all treated psychiatric illness in Lebanon over a 6-month period (February 15 to August 15, 1964) and by and large support the preceding findings. We have described elsewhere the methodology and general results of this research (Katchadourian, 1968 ; Katchadourian and Racy, 1969), the relationship of mental illness to social class (Katchadourian and Churchill, 1969 ; Katchadourian and Churchill, I973a), to education (Katchadourian and Churchill, I973b), and religion (Katchadourian, 1974a). A second series of papers deal with the major diagnostic entities separately (Katchadourian and Sutherland, 1974a, 1974b, 1974c, 1974d, 1974e). The information on drug addiction reported to us is quite comprehensive for those under psychiatric care. Since we also received information on all cases of addiction who were in jail through the psychiatric consultant to these institutions, our data actually include all addicts who came to legal as well as psychiatric attention over a 6-month period. In other words, we have information from all of the sources that Haikal has reported from as well as all cases seen by other psychiatrists in Lebanon. Nevertheless, our figures are quite incomplete, of course, so far as the overall population of drug addicts at large in the general population is concerned.
COMPONENTS OF PREVALENCE A total of 6,095 cases were reported to the study, constituting over 95% of all cases seen by psychiatrists during the study period. After those patients who were not Lebanese citizens or who were given nonpsychiatric diagnoses as well as a small number with inadequate diagnostic data were eliminated, we were left with 4,624 patients which constitutes the population from which the cases for this report are drawn. There are a total of 315 cases of drug addiction in this patient population constituting 7% of cases (16.1 per 100,000 for 6 months). As noted in earlier publications, important differences emerge when the patient population is examined for components in prevalence in addition to the overall period prevalence group (Katchadourian, 1969; Katchadourian and Churchill, 1969;Katchadourianand Churchill, 1973a,1973b).The threesubgroups singled out for this purpose are: the point prevalence group consisting of
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KATCHADOURIAN A N D SUTHERLAND
all patients under care on the first day of the study; the incidence group consisting of all patients who came under care for the first time during the study period; the readmissions group consisting of patients who have had an episode of psychiatric care in the past and who subsequently reentered care during the study period. When examined in these terms, 45% of drug addicts (142 cases) are found to be concentrated in the incidence group, 36% (1 12 cases) in the readmissions group, and only 19% percent (61 cases) are under care on any given day. In the patient population as a whole, the incidence group accounts for 42% of cases (99.4 per 100,000), the point prevalence group also for 42% of cases (100.5 per 100,000), and readmissions for 16% of cases (37.6 per 100,000).These patterns clearly indicate that relative to the general patient population there is a rapid turnover and a high rate of recidivism among drug addicts that come to psychiatric attention. The pattern of drug addicts contrasts even more markedly with that for conditions that tend to be chronic and require protracted uninterrupted care. For example, among schizophrenics new cases account for 20% (13.2 per lOO,OOO), the point prevalence group for 62% (42.9 per 100,000), and readmissions for 18% of cases (12.6 per 100,000).
DEMOGRAPHIC CHARACTERISTICS Sex
The sex distribution of the Lebanese general population is approximately even, but within the patient population, males account for 55% of cases. There are further differences in this regard in the various diagnostic entities. For example, among schizophrenics, males account for 60% of cases, while within the neurotic disorders females account for 59% of cases. The most extreme sex difference encountered in any diagnostic category involves drug addicts: 98% of all cases of drug addiction reported to the study are male (3 1.3 per 100,000) and only 2% female (0.8 per lO0,OOO). Additional information on sex distribution is provided in Tables 1 and 2. Since there are so few female patients, it is not possible to meaningfully compare sex differences within the three components of prevalence. The pattern nevertheless appears to be consistent with what was described above for each sex taken separately. In service investigations it is not possible, of course, to ascertain precisely to what extent prevalence rates from patients under care reflect true prevalence figures in the population at large. However, in view of the
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Table 1 Age Distribution of Drug Addicts in Lebanon by Sex ~
Males
Females
%
No.
Age
Total
%
No.
%
No.
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~
Unknown 1614 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 6G64 65-69 70-74 75 TOTALS
+
3 1 18 32 56 88 51 30 7 7 5 4 3 I 1
307
1.o 0.3 5.7 10.2 17.8 27.9 16.2 9.5 2.2 2.2 1.6 1.3 I .O 0.3 0.3
97.5
0 0 1 3 0 0 3 1
0 0 0 0 0 0 0 8
0.0 0.0 0.3 1 .O 0.0 0.0 1 .O 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.5
3
1 .o
1
0.3 6.0 11.1 17.8 21.9 17.1 9.8 2.2 2.2 1.6 1.3 1.o 0.3 0.3 100.0
19 35 56 88 54 31
I 7 5 4 3 I 1 -
315
Table 2 Marital Status of Drug Addicts in Lebanon by Sex
Males
Females
Total
Marital status
No.
%
No.
%
No.
%
Unknown Unmarried Married Previously married
9 159 116 23
2.9 50.5 36.8 7.3
0 3 4 1
0.0 1.o 1.3 0.3
9 162 120 24
2.9 51.4 38.1 I.6
307
-
-
-
-
-
97.5
8
2.5
315
100.0
TOTALS
overwhelming sex difference among treated addicts in Lebanon, one can conclude with virtual certainty that whatever service-related factors may be confounding the picture, the apparent sex difference in this group must at least to some measure reflect a higher rate of drug addiction among males in the population at large. Yet, what the possible causes for such a true difference in rates would be is another matter. Of course, one can speculate in this regard, but a study such as ours does not provide the necessary information to resolve such issues.
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The age distribution of drug addicts is presented for each sex in Table 1. There is a concentration of patients between the ages of 20-39 years in the general patient population where this group constitutes 52% of all the cases. This pattern is even more marked among drug addicts where 74% of all cases fall in this same age range. The single 5-year age bracket among drug addicts with the highest rate is that of the 3CL34 year old group which alone accounts for 28% of all cases. The age bracket preceding (25-29 years) and following it (35-39 years) each account for 17% of all cases. At the time of the study, psychedelic drugs had not yet reached Lebanon and, as is apparent from these figures, drug addiction was relatively rare in the younger age groups; only about 7% of all cases are younger than 20 years of age. At the other end of the spectrum, there is a sharp drop of rates beginning with age 45 years. All drug addicts above the age of 45 years account for only 9% of all cases of addiction reported to the study. Marital Status
The marital status of drug addicts is presented for each sex in Table 2. In the general patient population, unmarried patients account for 56% of cases, those married for 35%, and the previously married for 6%. Specific diagnostic entities differ in this regard : In the schizophrenic group there is a predominance of unmarried patients who account for 67% of cases; among affective psychotics the married patients account for 60% of cases. In terms of marital status, drug addicts seem to be intermediate between the groups referred to above and quite close to the pattern of the general patient population. The unmarried among addicts account for 51% of cases, the married for 38%, and the previously married for 8%. Unfortunately, we have no information on the marital status of the general Lebanese population. As a result, the usefulness of these rates is limited to comparing one diagnostic entity with another.
SOCIAL CHARACTER lSTl CS Income
The procedure which we used for determining social class by level of income has been described earlier (Katchadourian and Churchill, 1969).
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When all urban patients were considered as a group, a statistically significant association was found between class position as determined by estimated family income and the prevalence of psychiatric disorders. Patients were found to be overrepresented in the lower class, and this relationship persisted when the factors of age, sex, marital status, and religion were controlled. A similar significant association was found to exist between class position and types of psychiatric disorders : neurotic disorders were shown to be overrepresented in the upper class and psychotic disorders in the lower class (Katchadourian and Churchill, 1969). When the patient population was examined in terms of the various components in prevalence, a significant association was shown to exist in the incidence group between social class and the prevalence of illness, with the upper class showing the highest rate by a small margin. But in the patient population under care at the onset of the study, lower class patients were quite predominant and the same was true for patients readmitted to care during the study period. Among neurotic patients, there were higher rates for the upper class in the incidence and point prevalence group, and lower class patients had the highest rates among psychotics in all three components of prevalence. The class discrepancies among drug addicts are even more exaggerated. In the 89% of cases with information on income level, 84% of all cases come from the lowest income group, 15% from the middle, and 176 from the upper income group. In the 11o/o of cases that lacked information on income, probably the majority of cases were also poor. Since there are no corresponding figures for the income distribution of the Lebanese general population, the above rates cannot be evaluated in definitive terms. But we can make comparisons with the general urban population where we have information on income distribution (Katchadourian and Churchill, 1969). A total of 227 urban addicts were reported to the study. They constitute 72% of all addicts in the patient population even though the urban general population accounts for only about half the overall Lebanese population. Table 3 compares the percentage distribution within three income categories of drug addicts and nonpatients in the Lebanese urban population. The total of 207 cases in Table 3 excludes 20 cases with no information as to level of income. Since all but seven of these 207 are male, the data is not presented for each sex separately. There is a striking inverse relationship between income level and prevalence of addiction in Table 3. The percentage of upper income addicts is less than a tenth and that of middle income addicts less than half of what one would expect. On the other hand, there are over twice as many addicts
KATCHADOURIAN AND SUTHERLAND
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Table 3 Income Level of Drug Addicts and Nonpatients in the Urban Population' Nonpatients
Drug addicts
Income level
No.
%
~~~~~
2 39 166
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Upper
Middle Lower TOTALS
"x2 = 144.7142, df = 2, p
=
No. ~
1 19 80
~
~
~
%
~~~~~~~
239 1,151 83 1
-
-
-
207
100
2,221
11
52 37 100
< .005.
in the lower income group than expected on the basis of the income distribution of the general urban population. While service-related considerations are obviously relevant in this regard, it is quite likely that this apparent class discrepancy reflects differences in the true prevalence of addiction in the population at large. Education
The relationship of educational level to the prevalence of illness is quite similar to that of income for the general patient population (Katchadourian and Churchill, 1973b). Because of the close association of these these two variables, the patterns that emerge are inevitably redundant to some extent. Unfortunately, it is not possible to effectively control for the interplay of these factors because of the close overlap in the distribution of the two component populations. In other words, one does not encounter sufficiently large numbers of well-educated poor, or poorly educated rich for purposes of control. The information on the relationship of educational level to the prevalance of drug addiction is compromised by the fact that we have no data in this regard reported for 29% of cases. In the balance of cases, when there is such information, patients with no more than a grade school education account for 79% of cases, those who have had at least 6 years of schooling but no more than 11 years of schooling account for 21% of cases. Only one individual is reported in this group to have been to college. There is some reason to believe that currently in Lebanon one would encounter a somewhat higher proportion of higher educated individuals having difficulties with drug addiction, primarily because of the increased use of these agents by college students.
DRUG ADDICTION IN LEBANON
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Table 4 Educational Level of Drug Addicts and Nonpatients in the Urban Population' ~
~
~
~~
Drug addicts
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Educational level Upper Middle Lower TOTALS
x
a 2 -
-
52.1922, df
=
No.
%
1 42 123 166
1 25 14 100
~
Nonpatients No. 391 735 1,043 2,169
% 18 34 48
100
2, p < .005.
When the urban drug addicts are compared to their educational counterparts in the population at large, a significant association emerges. As shown in Table 4, there is an inverse relation between educational level and the prevalence of illness. The question again arises as to whether these observed differences between educational levels merely reflect that the better educated and more affluent addicts manage to sustain their habits without coming to psychiatric or legal attention and thus would be underrepresented in a patient population such as ours. As indicated in connection with income level discrepancies, such factors undoubtedly distort the picture. Yet the differences are marked enough to make us consider the alternative explanation that the observed differences in rates are at least in part a reflection of true differences in prevalence. General observation in Lebanon as well as elsewhere in the Arab world also seems to confirm the notion that there is a heavy concentration of drug abuse among the poor and uneducated whether they come to medical or legal attention or not. Religion
The Lebanese population is about evenly divided between Christians and Moslems. There are important differences, however, within the patient population where Christians account for 61% (290.1 per lO0,OOO) and Moslems for 38% (177.9 per 100,000) of cases. The social significance of religious affiliation in Lebanon and its relationship to the prevalence of mental illness as a whole have been dealt with in considerable detail in a previous publication (Katchadourian, 1974a). To place our discussion of the relation of drug addiction to religious affiliation in perspective, let us briefly consider the association of religions
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KATCHADOURIAN AND SUTHERLAND
Table 5 Religion and Mental Illness in Lebanon, Rates for 100,000 Population
Period prevalence
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~~~
Christian Male Female TOTALS Moslem Male Female TOTALS
~
~
~
~
Point prevalence ~~
~
Incidence
Readmissions
116.5
~
289.0 291.2 290.1
130.9 139.2 135.0
115.1 115.8
41.6 36.9 39.2
222.7 132.6 177.9
73.8 50.4 62.2
102.5 58.5 80.6
46.2 23.1 35.0
with the overall rates of mental illness in Lebanon. As indicated in Table 5, the rates for Christians are consistently higher than for Moslems in all but one category. The only exception is the readmissions rate for males where the rate for Moslems is somewhat higher than that for Christians. The predominence of Christians in the general patient population is at least in part explicable by the readier access that Christians have to psychiatric facilities (Katchadourian, 1974a). The only exception noted where Moslems have a higher rate is due to the preponderance of Moslem males among drug addicts who have a high recidivism rate, as we shall discuss shortly. In the drug addict group, the religious distribution of cases sharply contrasts to that of the general patient population. Moslems who are addicts account for 73% of all cases against 25% for Christians (the balance of 2% of cases have no information as to religious affiliation). Along with the marked sex discrepancy described above, this finding is one of the more dramatic in our data. Once again the question arises as to whether this apparent discrepancy in religious distribution reflects the true picture in the general population or is simply a reflection of the manner in which drug addicts are treated in Lebanon. While the relevance of service-related considerations cannot be underrated, the apparent discrepancy is so sharp that there can be little doubt that the preponderance of Moslems in the treated drug addict population must at least to some measure be a reflection of the preponderance of Moslems in the drug addict population at large. What the exact causes for this pattern are cannot be determined from our data. A possibly significant factor is that although alcohol is prohibited by the Koran, there is no comparable restriction against narcotic usage. On the other hand, alcoholism as such is rather rare in Lebanon, even among
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Christians, despite the presence of considerable social drinking in the country. It is important to note that the concentration of drug addicts among Moslems is not a function of there being more sociopathic disorders in general in this group. On the contrary, when sociopathic personality disorders are considered exclusive of drug addicts, 679/0 of cases emerge to be Christian and only 33% Moslem.
D IAG N OSTl C B R EA KD0W N The diagnostic problems ordinarily encountered in cross-cultural research are relatively less formidable in the case of drug addiction, so far as establishing the fact of drug usage is concerned. It is an entirely different matter, of course, if one is trying to determine etiological factors involved in addiction or the relationship of such usage to psychodynamic and social factors. The diagnostic scheme used in this study was that of the American Psychiatric Association (1965) current at the time (DSM I). Among the various types of addictive agents used, heroin is clearly the most prevalent among the patients reported to us. Heroin addicts account for 39% of all cases of addiction. When cases where heroin was used in combination with other drugs are also added, this group accounts for 59% of all cases (9.0 per 100,000 population. Since all of these cases are male, the rate for males alone is double or 18.0 per 100,000per 6 months). Next comes hashish which when used singly accounts for 187/,, and in combination with other drugs constitutes 29y0 of all cases (4.7 per 100,000 per 6 months. All but one of these cases are male and the rate for males only is 9.3 per 100,000). Heroin and hashish are used together in about 10% of cases. The balance of cases consists of small percentages each of cocaine, morphine, and opium usage. In about 20% of cases the type of drug is not specified, and we suspect that in the majority of these instances the addictive agent is also heroin.
REFERRAL AND TREATMENT Drug addiction is not a reportable disease in Lebanon. Thus a patient can seek medical help without fear of being apprehended through information supplied by the treating agency. A person can also go to the Ministry of Health Clinic and report that he is a drug addict and wants help, in which case he is admitted to the drug ward of the Lebanon Hospital for Nervous and Mental Disorders. As a voluntary patient, however, he can
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KATCHADOURIAN AND SUTHERLAND
leave if he wishes to. Actually these voluntary admissions usually involve individuals who suspect that they are about to be apprehended and take recourse to this procedure to avoid going to jail. Thus the provision for exemption from prosecution to encourage addicts to voluntarily seek treatment has become subverted to other ends. When a drug addict is apprehended by the police, he is kept under observation and questioning for a few days and then usually transferred to the central prison in Beirut. Soon after admission to prison the addict is seen by a social worker who takes a detailed history and presents the case to the state-appointed psychiatrist. If the addict is suffering from withdrawal symptoms, he is given tranquilizers and cared for by the prison hospital nurse or, if his condition requires it, he is transferred to the forensic unit of the Lebanon Hospital referred to above. At the time of this study there were 21 psychiatrists practicing in Lebanon, all of them in Beirut. They had had specialized training in psychiatry in the West and were conversant with the more standard therapeutic approaches to the treatment of drug addicts but none had extensive specialized training in this regard. Drug addicts in prison wait for their trial which usually comes up within 2 to 6 months. If convicted, they are sentenced for a period of up to 1 year for the first offense and 2 or more years for repeated offenses. If they are also convicted of being pushers, then the sentence is harsher. Once convicted, these individuals are referred to the psychiatric forensic unit provided there are vacancies. Many of them never get there, however, because these facilities are limited to 120 patients. During their stay in the forensic unit the addicts are “rehabilitated.” The process consists of some occupational therapy and associated activities, but does not include any psychotherapy to speak of. They essentially serve time. After 6 months, if they have behaved well, they are discharged, because the sentence stipulates that they be kept in the hospital “until cured,” but for a period of time not to exceed a certain length of time depending on the sentence. There are no aftercare or follow-up facilities or programs. In our patient population, information on the referral process was available on only 68% of drug cases. Within this group over half the cases (56%) were referred by the police or the courts. In other words, they were already in jail. Another 34% were referrals from other psychiatrists (usually the Ministry of Health consultant) to the hospital drug unit. Only 4% of cases were self-referred, and a similar number referred by members of the family. (In the general patient population, family referrals constitute the largest proportion of cases.) An additional 1% each of cases were referred by other physicians and friends.
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Of the patients reported to the study, only 72% of cases had information on the treatment process. Of these, 69% were said to be under custodial care; that is, merely serving the requisite period of time before leaving the institution. (In the 28% of cases where no specific treatment modality was mentioned, the majority probably would also fit in this group). In another 25% of cases, patients were reported as receiving “psychotherapy” and 524 were being given drugs. The psychotheraputic approach in these cases would primarily involve some form of supportive therapy. Particularly among the poor and less well-educated it would be highly unlikely to encounter patients who were undergoing intensive insight-oriented psychotherapy. The treatment of drug addicts at the time of our study was thus quite rudimentary. Recommendations were being made, however, for a more systematic and intensive approach. The possibilities for such advances are probably better understood in the historical context of psychiatric treatment in Lebanon (Katchadourian, 1974b).
SUMMARY A comprehensive survey of all treated psychiatric illness over a 6-month period was conducted in Lebanon. This paper presents the data on 315 cases of drug addiction that were reported to the study. This information is analyzed in terms of components in prevalence and the independent variables of sex, age, marital status, income, education, and religion. The distribution of patients in the subcategories of drug addiction are presented and the referral and treatment processes discussed. The three key findings are the striking concentration of drug addicts among males, in the lower income group, and among Moslems. ACKNOWLEDGMENTS
This investigation was supported in whole by Public Health Service Research Grant M H 06810 from the National Institute of Mental Health, U.S. Public Health Service, Bethesda, Maryland. It was carried out at the American University of Beirut, Beirut, Lebanon. The final data analyses and writing were begun when both authors were at Stanford, where Katchadourian was a University Fellow. During the last phase of writing, Sutherland was an instructor at the U.S.A.F. Academy. The views expressed here do not necessarily reflect those of the Academy. We are most grateful for the collaboration of the directors of the psychiatric institutions in Lebanon, Drs. H. Ayoub, A. Labban, and A.
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Manugian, and of the participating psychiatrists. Drs. Lyman C . Wynne and John Racy have been most helpful during the various phases of this research.
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REFERENCES AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual (DSM I ) Mental Disorders. Washington, D.C., 1965. KATCHADOURIAN, H.A. A survey of treated psychiatric illness in Lebanon. Brit. J. Psychiat. 114: 21-29, 1968. KATCHADOURIAN, H.A. A comparative study of mental illness among the Christians and Moslems of Lebanon, Znt. J. Soc. Psychiat. 20(1-2): 56-57, 1974a. KATCHADOURIAN, H.A. The historical background of psychiatry in Lebanon. Bull. Hist. Med. 1974b. Submitted for publication. KATCHADOURIAN, H.A., and CHURCHILL, C. W. Social class and mental illness in urban Lebanon. SOC.Psychiat. 4:49-55, 1969. KATCHADOURIAN, H.A., and CHURCHILL, C.W. Components in prevalence of mental illness and social class in urban Lebanon. SOC.Psychiat. 8: 145-151,1973a. KATCHADOURIAN, H.A., and CHURCHILL, C.W. Education and mental illness in urban Lebanon. SOC.Psychiat. 8: 152-161, 197313. KATCHADOURIAN, H.A., and RACY, J. The diagnostic distribution of treated psychiatric illness in Lebanon. Brit. J. Psychiat. 115: 1309-1322, 1969. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Affective psychoses in Lebanon. Lebanese Med. J. 1974a. In press. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Neurotic disorders in Lebanon. Lebanese Med. J . 1914b. In press. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Organic brain syndromes in Lebanon. Lebanese Med. J. 1974c. In press. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Personality disorders in Lebanon. Lebanese Med. J. 1974d. In press. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Schizophrenic disorders in Lebanon. Lebanese Med. J. 1974e. In press. RACY, J. Psychiatry in the Arab East (Acra Psychiat. Scand. Suppl. 211). Copenhagen: Munksgaard, 1970. WEISSMAN, P. New York Herald Tribune, April 9, 1965.
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Psychiatric Aspects of Drug Addiction in Lebanon Herant A. Katchadourian & Jeffrey V. Sutherland To cite this article: Herant A. Katchadourian & Jeffrey V. Sutherland (1975) Psychiatric Aspects of Drug Addiction in Lebanon, International Journal of the Addictions, 10:6, 949-962, DOI: 10.3109/10826087509028353 To link to this article: http://dx.doi.org/10.3109/10826087509028353
Published online: 03 Jul 2009.
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Date: 25 April 2016, At: 22:27
The International Journal of the Addictions, lo(@, pp. 949-962, 1975
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Psychiatric Aspects of Drug Addiction in Lebanon Herant A. Katchadourian, M.D. Stanford Medical Center Stanford, California
Jeffrey V. Sutherland, M.S.* Department of Mathematics United States Air Force Academy, Colorado
The problem of narcotics abuse in Lebanon is significant on several counts. There is a tradition of hashish usage in the area that goes back many centuries. In more recent times, Lebanon has been identified as an important way-station in the international heroin traffic that moves Turkish opium to Lebanon where it is converted to morphine base, and on to Marseille where it is further processed to heroin destined for New York (Weissman, 1965). Also, Lebanon itself produces a considerable amount of hashish for local consumption as well as presumably for export. According to one account, the more extensive growing of hashish in Lebanon dates back to 1922 when it was introduced by an Ottoman officer
* To whom correspondence should be addressed at the Department of Biometrics, University of Colorado Medical Center, 4200 East Ninth Avenue, Denver, Colorado 80220. 949 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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to the Beqa’a valley where it is now primarily grown. Given the suitable climatic and soil conditions, its cultivation has since then rapidly spread so that by the midsixties the yearly output was estimated at about 150 tons. Governmental agencies have been quite aware of this situation but have not instituted rigorous control measures since the economy of some 50 to 60 villages in the area is based on this product. Since wholesale destruction of the hashish fields would leave substantial numbers of peasants destitute, one experimental plan has been to help hashish growers to shift to the cultivation of sunflowers, which would do equally well in the arid climate and whose seeds could provide a marketable substitute cash crop. Arab states have traditionally paid little attention to the problem of drug addiction within their countries. This has been partly due to ignorance of the extent of the problem reinforced by the fiction that while people admittedly export these products, they are “too smart” to use it themselves. It has also been alleged that powerful political figures with investments in such trade have successfully blocked effective control measures. During the past decade or so, these attitudes have changed somewhat and there is now a t least a recognition of the seriousness of the problem. Drug addiction is predominantly a lower income class phenomenon in Lebanon almost exclusively involving males. Until and unless drug use interferes with a man’s earning his livelihood, it is unlikely to attract adverse notice within the user’s immediate community. The middle class population is vaguely aware of the issue, mostly through periodic magazine articles that highlight the more dramatic aspects of drug traffic. In one suburb of Beirut a physician who was a known and severe morphine addict was openly tolerated and continued to practice for years although people did not have much confidence in his judgment. There are no extensive or accurate statistics about the prevalence of drug addiction in Lebanon or the rest of the Arab East. In a comprehensive survey of the psychiatric literature on this area, Racy lists a number of studies from Egypt and the Sudan by El-Maghrabi, Soueif, and El-Mahi as well as a number of review papers for the World Health Organization by the last author (Racy, 1970). There is also one reference to addiction in Lebanon abstracted from the 1962 Annual Report of the Ministry of Public Health based on data provided by J. Haikal, the psychiatric consultant to the Ministry for problems of drug addiction. Haikal’s figures include all drug addicts who were in jail and in the forensic unit of the Lebanon Hospital for Mental and Nervous Disorders at Asfurieh. As summarized by Racy, Haikal’s statistics are as follows: 90% of addicts are male; heroin is the most frequently used agent (hashish and
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cocaine come next); 87.5% of all addicts are 20-39 years old; 85% of all addicts come from the lowest socioeconomic class and most are laborers; 97% of the addicts are close to illiteracy (very little or no schooling); 50% start addiction “under the influence of friends and environment”; and about 90% come from Beirut and its suburbs. The total number treated at the hospital in 1962 was 257; 51% were readmissions (Racy, 1970). The data reported here emanate from a comprehensive survey of all treated psychiatric illness in Lebanon over a 6-month period (February 15 to August 15, 1964) and by and large support the preceding findings. We have described elsewhere the methodology and general results of this research (Katchadourian, 1968 ; Katchadourian and Racy, 1969), the relationship of mental illness to social class (Katchadourian and Churchill, 1969 ; Katchadourian and Churchill, I973a), to education (Katchadourian and Churchill, I973b), and religion (Katchadourian, 1974a). A second series of papers deal with the major diagnostic entities separately (Katchadourian and Sutherland, 1974a, 1974b, 1974c, 1974d, 1974e). The information on drug addiction reported to us is quite comprehensive for those under psychiatric care. Since we also received information on all cases of addiction who were in jail through the psychiatric consultant to these institutions, our data actually include all addicts who came to legal as well as psychiatric attention over a 6-month period. In other words, we have information from all of the sources that Haikal has reported from as well as all cases seen by other psychiatrists in Lebanon. Nevertheless, our figures are quite incomplete, of course, so far as the overall population of drug addicts at large in the general population is concerned.
COMPONENTS OF PREVALENCE A total of 6,095 cases were reported to the study, constituting over 95% of all cases seen by psychiatrists during the study period. After those patients who were not Lebanese citizens or who were given nonpsychiatric diagnoses as well as a small number with inadequate diagnostic data were eliminated, we were left with 4,624 patients which constitutes the population from which the cases for this report are drawn. There are a total of 315 cases of drug addiction in this patient population constituting 7% of cases (16.1 per 100,000 for 6 months). As noted in earlier publications, important differences emerge when the patient population is examined for components in prevalence in addition to the overall period prevalence group (Katchadourian, 1969; Katchadourian and Churchill, 1969;Katchadourianand Churchill, 1973a,1973b).The threesubgroups singled out for this purpose are: the point prevalence group consisting of
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all patients under care on the first day of the study; the incidence group consisting of all patients who came under care for the first time during the study period; the readmissions group consisting of patients who have had an episode of psychiatric care in the past and who subsequently reentered care during the study period. When examined in these terms, 45% of drug addicts (142 cases) are found to be concentrated in the incidence group, 36% (1 12 cases) in the readmissions group, and only 19% percent (61 cases) are under care on any given day. In the patient population as a whole, the incidence group accounts for 42% of cases (99.4 per 100,000), the point prevalence group also for 42% of cases (100.5 per 100,000), and readmissions for 16% of cases (37.6 per 100,000).These patterns clearly indicate that relative to the general patient population there is a rapid turnover and a high rate of recidivism among drug addicts that come to psychiatric attention. The pattern of drug addicts contrasts even more markedly with that for conditions that tend to be chronic and require protracted uninterrupted care. For example, among schizophrenics new cases account for 20% (13.2 per lOO,OOO), the point prevalence group for 62% (42.9 per 100,000), and readmissions for 18% of cases (12.6 per 100,000).
DEMOGRAPHIC CHARACTERISTICS Sex
The sex distribution of the Lebanese general population is approximately even, but within the patient population, males account for 55% of cases. There are further differences in this regard in the various diagnostic entities. For example, among schizophrenics, males account for 60% of cases, while within the neurotic disorders females account for 59% of cases. The most extreme sex difference encountered in any diagnostic category involves drug addicts: 98% of all cases of drug addiction reported to the study are male (3 1.3 per 100,000) and only 2% female (0.8 per lO0,OOO). Additional information on sex distribution is provided in Tables 1 and 2. Since there are so few female patients, it is not possible to meaningfully compare sex differences within the three components of prevalence. The pattern nevertheless appears to be consistent with what was described above for each sex taken separately. In service investigations it is not possible, of course, to ascertain precisely to what extent prevalence rates from patients under care reflect true prevalence figures in the population at large. However, in view of the
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Table 1 Age Distribution of Drug Addicts in Lebanon by Sex ~
Males
Females
%
No.
Age
Total
%
No.
%
No.
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~
Unknown 1614 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 6G64 65-69 70-74 75 TOTALS
+
3 1 18 32 56 88 51 30 7 7 5 4 3 I 1
307
1.o 0.3 5.7 10.2 17.8 27.9 16.2 9.5 2.2 2.2 1.6 1.3 I .O 0.3 0.3
97.5
0 0 1 3 0 0 3 1
0 0 0 0 0 0 0 8
0.0 0.0 0.3 1 .O 0.0 0.0 1 .O 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.5
3
1 .o
1
0.3 6.0 11.1 17.8 21.9 17.1 9.8 2.2 2.2 1.6 1.3 1.o 0.3 0.3 100.0
19 35 56 88 54 31
I 7 5 4 3 I 1 -
315
Table 2 Marital Status of Drug Addicts in Lebanon by Sex
Males
Females
Total
Marital status
No.
%
No.
%
No.
%
Unknown Unmarried Married Previously married
9 159 116 23
2.9 50.5 36.8 7.3
0 3 4 1
0.0 1.o 1.3 0.3
9 162 120 24
2.9 51.4 38.1 I.6
307
-
-
-
-
-
97.5
8
2.5
315
100.0
TOTALS
overwhelming sex difference among treated addicts in Lebanon, one can conclude with virtual certainty that whatever service-related factors may be confounding the picture, the apparent sex difference in this group must at least to some measure reflect a higher rate of drug addiction among males in the population at large. Yet, what the possible causes for such a true difference in rates would be is another matter. Of course, one can speculate in this regard, but a study such as ours does not provide the necessary information to resolve such issues.
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The age distribution of drug addicts is presented for each sex in Table 1. There is a concentration of patients between the ages of 20-39 years in the general patient population where this group constitutes 52% of all the cases. This pattern is even more marked among drug addicts where 74% of all cases fall in this same age range. The single 5-year age bracket among drug addicts with the highest rate is that of the 3CL34 year old group which alone accounts for 28% of all cases. The age bracket preceding (25-29 years) and following it (35-39 years) each account for 17% of all cases. At the time of the study, psychedelic drugs had not yet reached Lebanon and, as is apparent from these figures, drug addiction was relatively rare in the younger age groups; only about 7% of all cases are younger than 20 years of age. At the other end of the spectrum, there is a sharp drop of rates beginning with age 45 years. All drug addicts above the age of 45 years account for only 9% of all cases of addiction reported to the study. Marital Status
The marital status of drug addicts is presented for each sex in Table 2. In the general patient population, unmarried patients account for 56% of cases, those married for 35%, and the previously married for 6%. Specific diagnostic entities differ in this regard : In the schizophrenic group there is a predominance of unmarried patients who account for 67% of cases; among affective psychotics the married patients account for 60% of cases. In terms of marital status, drug addicts seem to be intermediate between the groups referred to above and quite close to the pattern of the general patient population. The unmarried among addicts account for 51% of cases, the married for 38%, and the previously married for 8%. Unfortunately, we have no information on the marital status of the general Lebanese population. As a result, the usefulness of these rates is limited to comparing one diagnostic entity with another.
SOCIAL CHARACTER lSTl CS Income
The procedure which we used for determining social class by level of income has been described earlier (Katchadourian and Churchill, 1969).
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When all urban patients were considered as a group, a statistically significant association was found between class position as determined by estimated family income and the prevalence of psychiatric disorders. Patients were found to be overrepresented in the lower class, and this relationship persisted when the factors of age, sex, marital status, and religion were controlled. A similar significant association was found to exist between class position and types of psychiatric disorders : neurotic disorders were shown to be overrepresented in the upper class and psychotic disorders in the lower class (Katchadourian and Churchill, 1969). When the patient population was examined in terms of the various components in prevalence, a significant association was shown to exist in the incidence group between social class and the prevalence of illness, with the upper class showing the highest rate by a small margin. But in the patient population under care at the onset of the study, lower class patients were quite predominant and the same was true for patients readmitted to care during the study period. Among neurotic patients, there were higher rates for the upper class in the incidence and point prevalence group, and lower class patients had the highest rates among psychotics in all three components of prevalence. The class discrepancies among drug addicts are even more exaggerated. In the 89% of cases with information on income level, 84% of all cases come from the lowest income group, 15% from the middle, and 176 from the upper income group. In the 11o/o of cases that lacked information on income, probably the majority of cases were also poor. Since there are no corresponding figures for the income distribution of the Lebanese general population, the above rates cannot be evaluated in definitive terms. But we can make comparisons with the general urban population where we have information on income distribution (Katchadourian and Churchill, 1969). A total of 227 urban addicts were reported to the study. They constitute 72% of all addicts in the patient population even though the urban general population accounts for only about half the overall Lebanese population. Table 3 compares the percentage distribution within three income categories of drug addicts and nonpatients in the Lebanese urban population. The total of 207 cases in Table 3 excludes 20 cases with no information as to level of income. Since all but seven of these 207 are male, the data is not presented for each sex separately. There is a striking inverse relationship between income level and prevalence of addiction in Table 3. The percentage of upper income addicts is less than a tenth and that of middle income addicts less than half of what one would expect. On the other hand, there are over twice as many addicts
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Table 3 Income Level of Drug Addicts and Nonpatients in the Urban Population' Nonpatients
Drug addicts
Income level
No.
%
~~~~~
2 39 166
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Upper
Middle Lower TOTALS
"x2 = 144.7142, df = 2, p
=
No. ~
1 19 80
~
~
~
%
~~~~~~~
239 1,151 83 1
-
-
-
207
100
2,221
11
52 37 100
< .005.
in the lower income group than expected on the basis of the income distribution of the general urban population. While service-related considerations are obviously relevant in this regard, it is quite likely that this apparent class discrepancy reflects differences in the true prevalence of addiction in the population at large. Education
The relationship of educational level to the prevalence of illness is quite similar to that of income for the general patient population (Katchadourian and Churchill, 1973b). Because of the close association of these these two variables, the patterns that emerge are inevitably redundant to some extent. Unfortunately, it is not possible to effectively control for the interplay of these factors because of the close overlap in the distribution of the two component populations. In other words, one does not encounter sufficiently large numbers of well-educated poor, or poorly educated rich for purposes of control. The information on the relationship of educational level to the prevalance of drug addiction is compromised by the fact that we have no data in this regard reported for 29% of cases. In the balance of cases, when there is such information, patients with no more than a grade school education account for 79% of cases, those who have had at least 6 years of schooling but no more than 11 years of schooling account for 21% of cases. Only one individual is reported in this group to have been to college. There is some reason to believe that currently in Lebanon one would encounter a somewhat higher proportion of higher educated individuals having difficulties with drug addiction, primarily because of the increased use of these agents by college students.
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Table 4 Educational Level of Drug Addicts and Nonpatients in the Urban Population' ~
~
~
~~
Drug addicts
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Educational level Upper Middle Lower TOTALS
x
a 2 -
-
52.1922, df
=
No.
%
1 42 123 166
1 25 14 100
~
Nonpatients No. 391 735 1,043 2,169
% 18 34 48
100
2, p < .005.
When the urban drug addicts are compared to their educational counterparts in the population at large, a significant association emerges. As shown in Table 4, there is an inverse relation between educational level and the prevalence of illness. The question again arises as to whether these observed differences between educational levels merely reflect that the better educated and more affluent addicts manage to sustain their habits without coming to psychiatric or legal attention and thus would be underrepresented in a patient population such as ours. As indicated in connection with income level discrepancies, such factors undoubtedly distort the picture. Yet the differences are marked enough to make us consider the alternative explanation that the observed differences in rates are at least in part a reflection of true differences in prevalence. General observation in Lebanon as well as elsewhere in the Arab world also seems to confirm the notion that there is a heavy concentration of drug abuse among the poor and uneducated whether they come to medical or legal attention or not. Religion
The Lebanese population is about evenly divided between Christians and Moslems. There are important differences, however, within the patient population where Christians account for 61% (290.1 per lO0,OOO) and Moslems for 38% (177.9 per 100,000) of cases. The social significance of religious affiliation in Lebanon and its relationship to the prevalence of mental illness as a whole have been dealt with in considerable detail in a previous publication (Katchadourian, 1974a). To place our discussion of the relation of drug addiction to religious affiliation in perspective, let us briefly consider the association of religions
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Table 5 Religion and Mental Illness in Lebanon, Rates for 100,000 Population
Period prevalence
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~~~
Christian Male Female TOTALS Moslem Male Female TOTALS
~
~
~
~
Point prevalence ~~
~
Incidence
Readmissions
116.5
~
289.0 291.2 290.1
130.9 139.2 135.0
115.1 115.8
41.6 36.9 39.2
222.7 132.6 177.9
73.8 50.4 62.2
102.5 58.5 80.6
46.2 23.1 35.0
with the overall rates of mental illness in Lebanon. As indicated in Table 5, the rates for Christians are consistently higher than for Moslems in all but one category. The only exception is the readmissions rate for males where the rate for Moslems is somewhat higher than that for Christians. The predominence of Christians in the general patient population is at least in part explicable by the readier access that Christians have to psychiatric facilities (Katchadourian, 1974a). The only exception noted where Moslems have a higher rate is due to the preponderance of Moslem males among drug addicts who have a high recidivism rate, as we shall discuss shortly. In the drug addict group, the religious distribution of cases sharply contrasts to that of the general patient population. Moslems who are addicts account for 73% of all cases against 25% for Christians (the balance of 2% of cases have no information as to religious affiliation). Along with the marked sex discrepancy described above, this finding is one of the more dramatic in our data. Once again the question arises as to whether this apparent discrepancy in religious distribution reflects the true picture in the general population or is simply a reflection of the manner in which drug addicts are treated in Lebanon. While the relevance of service-related considerations cannot be underrated, the apparent discrepancy is so sharp that there can be little doubt that the preponderance of Moslems in the treated drug addict population must at least to some measure be a reflection of the preponderance of Moslems in the drug addict population at large. What the exact causes for this pattern are cannot be determined from our data. A possibly significant factor is that although alcohol is prohibited by the Koran, there is no comparable restriction against narcotic usage. On the other hand, alcoholism as such is rather rare in Lebanon, even among
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Christians, despite the presence of considerable social drinking in the country. It is important to note that the concentration of drug addicts among Moslems is not a function of there being more sociopathic disorders in general in this group. On the contrary, when sociopathic personality disorders are considered exclusive of drug addicts, 679/0 of cases emerge to be Christian and only 33% Moslem.
D IAG N OSTl C B R EA KD0W N The diagnostic problems ordinarily encountered in cross-cultural research are relatively less formidable in the case of drug addiction, so far as establishing the fact of drug usage is concerned. It is an entirely different matter, of course, if one is trying to determine etiological factors involved in addiction or the relationship of such usage to psychodynamic and social factors. The diagnostic scheme used in this study was that of the American Psychiatric Association (1965) current at the time (DSM I). Among the various types of addictive agents used, heroin is clearly the most prevalent among the patients reported to us. Heroin addicts account for 39% of all cases of addiction. When cases where heroin was used in combination with other drugs are also added, this group accounts for 59% of all cases (9.0 per 100,000 population. Since all of these cases are male, the rate for males alone is double or 18.0 per 100,000per 6 months). Next comes hashish which when used singly accounts for 187/,, and in combination with other drugs constitutes 29y0 of all cases (4.7 per 100,000 per 6 months. All but one of these cases are male and the rate for males only is 9.3 per 100,000). Heroin and hashish are used together in about 10% of cases. The balance of cases consists of small percentages each of cocaine, morphine, and opium usage. In about 20% of cases the type of drug is not specified, and we suspect that in the majority of these instances the addictive agent is also heroin.
REFERRAL AND TREATMENT Drug addiction is not a reportable disease in Lebanon. Thus a patient can seek medical help without fear of being apprehended through information supplied by the treating agency. A person can also go to the Ministry of Health Clinic and report that he is a drug addict and wants help, in which case he is admitted to the drug ward of the Lebanon Hospital for Nervous and Mental Disorders. As a voluntary patient, however, he can
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KATCHADOURIAN AND SUTHERLAND
leave if he wishes to. Actually these voluntary admissions usually involve individuals who suspect that they are about to be apprehended and take recourse to this procedure to avoid going to jail. Thus the provision for exemption from prosecution to encourage addicts to voluntarily seek treatment has become subverted to other ends. When a drug addict is apprehended by the police, he is kept under observation and questioning for a few days and then usually transferred to the central prison in Beirut. Soon after admission to prison the addict is seen by a social worker who takes a detailed history and presents the case to the state-appointed psychiatrist. If the addict is suffering from withdrawal symptoms, he is given tranquilizers and cared for by the prison hospital nurse or, if his condition requires it, he is transferred to the forensic unit of the Lebanon Hospital referred to above. At the time of this study there were 21 psychiatrists practicing in Lebanon, all of them in Beirut. They had had specialized training in psychiatry in the West and were conversant with the more standard therapeutic approaches to the treatment of drug addicts but none had extensive specialized training in this regard. Drug addicts in prison wait for their trial which usually comes up within 2 to 6 months. If convicted, they are sentenced for a period of up to 1 year for the first offense and 2 or more years for repeated offenses. If they are also convicted of being pushers, then the sentence is harsher. Once convicted, these individuals are referred to the psychiatric forensic unit provided there are vacancies. Many of them never get there, however, because these facilities are limited to 120 patients. During their stay in the forensic unit the addicts are “rehabilitated.” The process consists of some occupational therapy and associated activities, but does not include any psychotherapy to speak of. They essentially serve time. After 6 months, if they have behaved well, they are discharged, because the sentence stipulates that they be kept in the hospital “until cured,” but for a period of time not to exceed a certain length of time depending on the sentence. There are no aftercare or follow-up facilities or programs. In our patient population, information on the referral process was available on only 68% of drug cases. Within this group over half the cases (56%) were referred by the police or the courts. In other words, they were already in jail. Another 34% were referrals from other psychiatrists (usually the Ministry of Health consultant) to the hospital drug unit. Only 4% of cases were self-referred, and a similar number referred by members of the family. (In the general patient population, family referrals constitute the largest proportion of cases.) An additional 1% each of cases were referred by other physicians and friends.
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Of the patients reported to the study, only 72% of cases had information on the treatment process. Of these, 69% were said to be under custodial care; that is, merely serving the requisite period of time before leaving the institution. (In the 28% of cases where no specific treatment modality was mentioned, the majority probably would also fit in this group). In another 25% of cases, patients were reported as receiving “psychotherapy” and 524 were being given drugs. The psychotheraputic approach in these cases would primarily involve some form of supportive therapy. Particularly among the poor and less well-educated it would be highly unlikely to encounter patients who were undergoing intensive insight-oriented psychotherapy. The treatment of drug addicts at the time of our study was thus quite rudimentary. Recommendations were being made, however, for a more systematic and intensive approach. The possibilities for such advances are probably better understood in the historical context of psychiatric treatment in Lebanon (Katchadourian, 1974b).
SUMMARY A comprehensive survey of all treated psychiatric illness over a 6-month period was conducted in Lebanon. This paper presents the data on 315 cases of drug addiction that were reported to the study. This information is analyzed in terms of components in prevalence and the independent variables of sex, age, marital status, income, education, and religion. The distribution of patients in the subcategories of drug addiction are presented and the referral and treatment processes discussed. The three key findings are the striking concentration of drug addicts among males, in the lower income group, and among Moslems. ACKNOWLEDGMENTS
This investigation was supported in whole by Public Health Service Research Grant M H 06810 from the National Institute of Mental Health, U.S. Public Health Service, Bethesda, Maryland. It was carried out at the American University of Beirut, Beirut, Lebanon. The final data analyses and writing were begun when both authors were at Stanford, where Katchadourian was a University Fellow. During the last phase of writing, Sutherland was an instructor at the U.S.A.F. Academy. The views expressed here do not necessarily reflect those of the Academy. We are most grateful for the collaboration of the directors of the psychiatric institutions in Lebanon, Drs. H. Ayoub, A. Labban, and A.
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Manugian, and of the participating psychiatrists. Drs. Lyman C . Wynne and John Racy have been most helpful during the various phases of this research.
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REFERENCES AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual (DSM I ) Mental Disorders. Washington, D.C., 1965. KATCHADOURIAN, H.A. A survey of treated psychiatric illness in Lebanon. Brit. J. Psychiat. 114: 21-29, 1968. KATCHADOURIAN, H.A. A comparative study of mental illness among the Christians and Moslems of Lebanon, Znt. J. Soc. Psychiat. 20(1-2): 56-57, 1974a. KATCHADOURIAN, H.A. The historical background of psychiatry in Lebanon. Bull. Hist. Med. 1974b. Submitted for publication. KATCHADOURIAN, H.A., and CHURCHILL, C. W. Social class and mental illness in urban Lebanon. SOC.Psychiat. 4:49-55, 1969. KATCHADOURIAN, H.A., and CHURCHILL, C.W. Components in prevalence of mental illness and social class in urban Lebanon. SOC.Psychiat. 8: 145-151,1973a. KATCHADOURIAN, H.A., and CHURCHILL, C.W. Education and mental illness in urban Lebanon. SOC.Psychiat. 8: 152-161, 197313. KATCHADOURIAN, H.A., and RACY, J. The diagnostic distribution of treated psychiatric illness in Lebanon. Brit. J. Psychiat. 115: 1309-1322, 1969. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Affective psychoses in Lebanon. Lebanese Med. J. 1974a. In press. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Neurotic disorders in Lebanon. Lebanese Med. J . 1914b. In press. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Organic brain syndromes in Lebanon. Lebanese Med. J. 1974c. In press. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Personality disorders in Lebanon. Lebanese Med. J. 1974d. In press. KATCHADOURIAN, H.A., and SUTHERLAND, J.V. Schizophrenic disorders in Lebanon. Lebanese Med. J. 1974e. In press. RACY, J. Psychiatry in the Arab East (Acra Psychiat. Scand. Suppl. 211). Copenhagen: Munksgaard, 1970. WEISSMAN, P. New York Herald Tribune, April 9, 1965.
